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DONATE ONE DIALYSIS KIT AND SAVE LIFE

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DONATE ONE DIALYSIS KIT AND SAVE LIFE

PLEASE DONATE ONE DIALYSIS KIT AND SAVE LIFE

APPLICATION FORM FOR DONATION OF ONE DIALYSIS KIT Chairman: Fr. DAVIS CHIRAMEL (KIDNEY FEDERATION OF INDIA)

COST OF ONE DIALYSIS KIT RS.1000/- (ONE THOUSAND RUPEES ONLY)

Name of the person making donation :

Age:

Date of Birth:

Gender / Sex

Male

Female

WFHS Health Card NO:

WFHS Marketing Executive Name:

WFHS Marketing Executive ID No:

Type of Health Card: Silver Gold Platinum

Address of person making donation :

Pin code :

State/type :

Landline / Telephone No :

Mobile / Whats App :

Email ID :

Number of dialysis kit :

Donation amount :

Method of donation : only through bank in Indian Rupees. No cash transaction allowed

Pravasies donation for One Dialysis Kit Rs.1000/- must be in Indian Rupees from NRE or NRO account only. (Foreign Currency is not accepted)

Whom to contact for making donation : Local/Gulf/Other countries marketing executive/ WFHS office

Bank transfer by : RTGS NEFT DD Personal cheque Credit card Debit card Google pay Phone pay Pay TM Other method of transfer

BENEFICIARIES BANK DETAILS

Name of Beneficiary :

A/C Number :

Bank Name :

Branch Name :

Place of Bank :

IFSC code No :

Amount transferred : Rs.

Amount in words:

REMITTER'S BANK DETAILS

Name of Remitter :

A/C Number :

Bank Name :

Branch Name :

Place of Bank :

IFSC code No :

Amount transferred : Rs.

Amount in words:

Note: Receipt will be send to your address by post/email. If any doubts, please contact directly to WFHS Office : 0487- 2445535

If any message to be send :

Place:

Name of Person Making donation:

Date:

Signature:

File:

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Managing Trustee, Wecare Family Health Scheme , Sun Tower Building, 4th Floor, Door No:3/147/48/26,East Fort, Thrissur- 680005
wfhsctrust@gmail.com
0487-2445535, 2429535, 2995535
Fax :1800-425-45535